Review each Avalon Medical Policy to identify necessary coding and enforcement updates. Application of proper ICD-10, CPT, and HCPCS coding to Avalon Medical Policies.Development of Avalon Medical Policy enforcement rules from medical and payment policies, to include rationale for interpretation, supporting evidence, and documentation. Identify and record coding and enforcement changes for each policy. Determine the impact of Client coding and enforcement variances based on Client policy adoption decisions. Coding and enforcement analysis and research as needed.

Provide consultative service and subject matter expertise in general and select coding-related services like CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding, using reference materials and tools to validate coding and abstracting to ensure correct payment. Produce reports highlighting audit findings, improvement opportunities, and detailed commentary to the client. Develops written reports summarizing findings and presenting to client. Conduct client sessions to review findings, recommendations, and best practices. Establishes and maintains strong, effective working relationships with clients, staff, client success team, and RCM (Revenue Cycle Management) division team members. Responsible for researching, revenues (codes) that apply to the business needs of internal and external customers. Liaison with business units with coding/configuration priority issues, and research questions and issues from internal customers relating to reimbursements, medical policy, and utilization. Excellent verbal and written communication skills. Efficient use of expenditures and resources (expense reports, timesheets) following budgetary guidelines.

Responsible for researching and analyzing the medical records when there is a discrepancy in coding, validating the coding, and supporting the department in the reporting of findings. I audited medical records to ensure compliance with the organization’s coding procedures and standards according to the CMS Coding Guidelines and Official ICD9 / ICD10 Coding Guidelines. Reviews insurance payments and denials and recommends coding corrections. Maintain compliance with CMS risk adjustment diagnosis coding guidelines. Perform comprehensive 1st pass reviews of medical records and physician assessment forms (HCC coding). Assist with the intake and quality assurance of medical records as necessary. Perform or participate in special projects as directed by management. Assist with contract negotiation, analyzes contractual requirements, identify contract deficiencies, and recommend changes. Ensure appropriate documentation and tracking of vendor information for multiple purposes, including audits, quality indicators, service scope, contract renewal, and cost-efficiency. Experience with manipulating large amounts of clinical and medical claims data while working in the healthcare industry, insurance, or related field is preferred.

Monitor, perform, and document peer review of code-level benefit definitions. Identify and implement opportunities for improvement. Create and maintain department SOPs and supporting process flows. Collaborate with Configuration to define business requirements associated with code-level data related to Member Benefits. Drive resolution of conflicts between benefits and code edit system.Research and interpret complex regulations across all markets to ensure compliance. Utilize correct coding guidelines across all product lines. Integrate Essential Health Benefits, State Provider agreements, CMS requirements, state-specific regulations, Mental Health Parity, etc., and resolve information source conflicts. Participate in annual benefit change process with Product leads and Member Benefits Analysts. Develop and utilize reports to analyze and stratify data in order to provide answers to member benefit issues identified within the department or by other departments. Collaborate with the Policy Department on Payment and Medical Policy development. Collaborate with Leadership and Member Benefits Analysts to communicate opportunities based on industry-standard coding practices. Participate in Cross-functional Projects and Market Regulatory meetings as the subject matter expert. Review, respond and implement Regulatory changes accurately and timely. Investigate and resolve complex issues. Serve as a mentor to other coding analysts. Build meaningful relationships with other teams and departments in the organization. Facilitate Cross-functional meetings. Manage implementation and maintenance of the Benefits Management Tool.

Conducts focused audits for medical coding compliance, healthcare fraud and abuse, and reimbursement guidelines in compliance with Government rules and regulations at Air Force headquarters level. Researches training opportunities, develops compliance training plans, and delivers standardized education/training to coder and provider audiences. As a project manager, ensures conformity with official coding policies, standards, requirements, and regulations then prepares reports on projects, business correspondence, and procedural manuals. Investigates and identifies compliance issues and analyzes practice patterns then recommends changes to policies and procedures for continuous process improvement. Assists with risk assessments, mitigation strategies, data collection, and statistical report generation. Meets regularly with headquarters leadership to redefine or establish operating program guides, policies, and procedures

The dispatch customer service representative is responsible for providing superior customer service. Answers incoming calls. Verifies, responds, and dispatches following company policies and procedures. Monitor customer property to detect and/or deter crimes. Notifies clients and law enforcement authorities about the detection of threats. Must be observant with a high level of concentration and be able to divide their attention in order to monitor multiple occurrences taking place in a single setting. Must be able to multitask and produce detailed quality work. Ability to use good judgment. Customer Focus, Problem Solving/Analysis, Time Management, Communication Proficiency, Teamwork Orientation, Technical Capacity, Proficient with computers, Good writing skills, and Handles conflicts.

Provide consultative service and subject matter expertise in general and select coding related services like CPT, HCPCS, ICD-10-CM, and ICD-10-PCS coding, uses reference materials and tools to validate coding and abstracting to ensure correct payment. Produce reports highlighting findings of audit, opportunities for improvement, and detailed commentary to the client. Develops written reports summarizing findings and presenting to client. Conduct client sessions to review findings, recommendations, and best practices. Establishes and maintains strong, effective working relationships with clients, staff, client success team and RCM (Revenue Cycle Management) division team members. Responsible for researching, revenues (codes) that are applicable to the business needs of internal and external customers. Liaison to business units with coding/configuration priority issues, and research questions and issues from internal customers as they relate to reimbursements, medical policy and utilization. Excellent verbal and written communication skills. Efficient use of expenditures and resources (expense reports, timesheets) in accordance with budgetary guidelines.

Performed inpatient and outpatient multi-specialty hospital coding and auditing via 3M and Pro-Health. Reviewed charts, entered HCC codes, and educated physicians on inaccurate HCC coding. Completed coding capture, HEDIS, HCC, and ICD-9 coding and auditing. Provided feedback and training to coding staff on quality assurance results. Provided staff coding training (ICD-9, ICD-10-CM, Medicare Risk Adjustment, Medicaid, professional coding, etc.). Maintained communication with management on progress toward meeting quality long and short-term goals. Conducted new employee orientation and scheduled training. Compiled quality assurance reports for top issues to be covered in quarterly coder training. Completed continuing education classes for coding proficiency and certification requirements.

Performed multi-specialty outpatient ICD-9 coding and auditing to include Evaluation and Management (E&M). Verified documentation for diagnostic, operational, and procedural coding and documentation accuracy and compliance to prevent or recapture lost revenue. Reviewed progress notes, physician orders, and consultation, laboratory, and radiology for terminology accuracy. The examined injury diagnoses case history for injury nature, cause, and setting. Analyzed provider documentation for accurate E&M CPT coding. Notified physicians when documentation was unavailable for coding and corrected documentation when physicians returned.

Performed multi-specialty inpatient and outpatient coding and auditing (including E&M) via Quadramed. Abstracted data from in/outpatient medical records, assigned codes, and documented patient care encounters. Performed in/outpatient ICD-9-CM, CPT-4, HCPC coding following VA, Joint Commission, ICD-9-CM, and DRG guidelines. Reviewed medical record audits for coding accuracy to increase revenue recovery (Visn #1, 12, 17, 20). Performed surgery, diagnostic study/procedure, outpatient encounter, inpatient professional fee, Agent Orange, Persian Gulf exam, Fee Basis, Contract Nursing Home (CNH) encounters for orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, physical therapy, occupational therapy, spinal cord injury, emergency room, laboratory, radiology, observation (23hr), gastrointestinal, endoscopy, blind rehabilitation, anesthesia, pathology, pharmacology, acute and long term psychiatry, nursing home hospice, and ambulatory surgery coding. Provided coding staff training (ICD-9, ICD-10, Medicare Risk Adjustment, Medicaid, professional coding, etc.). Provided feedback and training to coding staff on quality assurance

Performed multispecialty outpatient ICD-9-CM coding and auditing (including E&M). Utilized software programs to analyze and evaluate clinical documentation. Verified and edited clinical records for diagnostic/operation/procedure coding and documentation accuracy and compliance. Reviewed progress notes, physician orders, and consultation/laboratory/radiology for terminology accuracy. Examined injury diagnoses case history for injury nature, cause, and setting. Analyzed provider documentation for accurate E&M CPT coding. Notified physicians when documentation was unavailable for coding and corrected documentation with physicians.

Supervised 10 coders for the MRA/HCC remote project. Assisted with developing, updating, editing, and maintaining coding compliance plans. Abstracted pertinent information from patient medical records. Assigned appropriate ICD-10-CM codes, creating HCC and/or Rx HCC group assignments as applicable. Performed inpatient, outpatient, ICD-9CM coding, and auditing. Assigned Flagged Event codes when documentation in records were inadequate, ambiguous, or otherwise unclear for medical coding purposes. Remained current on medical coding guidelines and reimbursement reporting requirements. Reviewed chart assignments daily and accurately reported all hours worked on a weekly basis. Reported work-related concerns to assigned Coder Advocate and, if not adequately addressed, to Senior Manager of Clinical Operations. Complied with all HIPAA laws and regulations.

Supervised six coders for the MRA/HCC travel project. Developed and managed work schedules, organized workplace priorities and evaluated staff progress. Monitored patient care, diagnosis data, and service rendered medical necessity submitted on claim encounters. Trained providers, staff, and corporate/market departments on coding procedures. Monitored and inspected project costs and determined resource requirements. Verified that Medicare billing cycle and coding levels matched provider documentation. Defined, monitored and maintained coding productivity for providers and coding staff.

Responsible for the recruitment and hiring of 18 staff members. Oversaw staff, created workflows, developed and implement training programs, and conducted performance evaluations. Stayed up to date on State and Federal rules and regulations with regard to revenue cycle management, medical billing, coding, medical collection practices, and procedures. Reviewed failed audits for correction of patient registration and patient demographic changes. Reviewed charges from physician’s operative notes and office charge tickets. Expertly added specific data such as modifiers, payer specific information, including authorization criteria, CPT and ICD-10 code, date of admission, and date of injury (DOI) and asked for clarification from providers as needed. Understood and interpreted the Correct Coding Initiative (CCI) as it applies to charge entry work. Responsible for the processing and discrepancy reconciliation and closing of charge and payment batches. Successfully tracked and followed up on information requests from patients or payers. Responsible for ensuring all payments collected either prepayment or at time of service were posted as corresponding charges were posted. Responsible for posting all patient discounts. Responsible for the timely correction of any failed claim(s) within billing system, at clearing house, or via payer correspondence and/or EOB denial. Strong customer service skills; answered patient and insurance calls, promptly returned or followed up on all interactions, and prompted response to all requests for information, both internal and external. Posted insurance payments and contractual adjustments received by mail or via clearing house payment files. Knowledgeable of medical EOBs, patient deductibles, co-pays, and insurance or third party correspondence. Prepared accounts with past due to patient balances and transferred to collection agency.